Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
Return to the Presumptive Eligibility Page
This edition has three search options.
Prior guides may be located through the provider website archives.
Updated 06/15/2017
This publication supersedes all previous Presumptive Eligibility . Published by the Montana Department of Public Health & Human Services, July 2016 and prior. This manual was updated June 2017.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
06/152017 The manual was updated to include 2017 requirements and converted to a 508 compliant format.
The Affordable Care Act implemented new regulations giving hospitals and affiliated facilities participating with Medicaid, the option to make Presumptive Eligibility (PE) determinations for special populations. Note: Employees of County Health Departments or similar facilities who made Presumptive Eligibility determination for Pregnant Woman coverage prior to December 31, 2013 may continue to make these determinations after January 1, 2014 based on the new training and methodology, but may not make determinations for other coverage groups.
All providers electing PE must comply with State of Montana requirements for determining PE for the following groups:
► HMK Plus, formerly known as Children’s Medicaid
► HMK, formerly known as Children’s Health Insurance Program (CHIP)
► Parent/Caretaker Relative Medicaid
► Pregnant Woman
► Individuals age 19-64
► Former Foster Care (Individual Care, up to age 26)
► Breast and Cervical Cancer
Benefits for each of these groups vary according to the coverage group. Presumptive eligibility is SHORT TERM coverage. It is only available once every 12 months (or once per pregnancy) and lasts from the date of the determination until a determination of program eligibility is made, OR until the last day of the month following the month of determination, whichever is earlier.
Please contact us at any time if you have questions, need training or supplies, or need to verify information about presumptive eligibility.
Applicant:
Person applying for coverage for themselves, a spouse, or dependent child
Application:
The Presumptive Eligibility Application
Application for Health Coverage:
The “Application for Health Coverage & Help Paying Costs” used to apply for ongoing health coverage for Medicaid, HMK, or HMK Plus. Appendices A, B, or C may need to be completed if they apply.
Breast and Cervical Cancer:
Women ages 19 through 64 who have been screened and diagnosed with breast or cervical cancer; applicants must present 3 required forms and must not have other insurance which covers cancer treatment.
Determination:
Eligibility decision for Presumptive Eligibility (PE) coverage.
Determination Date:
The date a presumptive eligibility decision is made by a Qualified Entity (QE).
Eligibility Period:
Presumptive Eligibility coverage starts on the date of determination and ends the earlier of: the date a determination of ongoing program eligibility is made, or the end of the month following the month of the PE determination. An applicant may have only one PE period in 12 months, or only one PE Period per pregnancy.
Federal Poverty Level (FPL):
Poverty guidelines for the 48 contiguous stated and the District of Columbia as published under the “Annual Update on HHS Poverty Guidelines” in the Federal Register each year, on or about February 15. The FPL is used in combination with household size to determine presumptive eligibility.
Former Foster Care between ages 18 and 26: Individuals who were in Foster Care and receiving Medicaid when they turned 18. May apply for PE if between ages 18 and 25(until age 26), and should be evaluated for PE as an individual even if living in a household with other family members. No Income limits apply.
Health Montana Kids (HMK):
Formerly known as the Children’s Health Insurance Plan(CHIP), HMK serves eligible children up to age 19 in households with income between 144% and 261% of the FPL.
Health Montana Kids Plus (HMK Plus):
Formerly known as Children’s Medicaid, HMK Plus serves eligible children up to age 19 in households with incomes between 0% and 143% of the FPL.
Income Calculation Tool:
Reference table identifying household size and corresponding maximum income levels for persons or households applying for Presumptive Eligibility.
Individuals ages 19-64:
This expansion group covers individuals ages 19-64 that are not pregnant at the time of application, not eligible for or enrolled in Medicare Part A, not enrolled in Medicare Part B and are between 24% and 133% of the FPL.
Parent/Caretaker Relative Medicaid:
For individuals living together and related by marriage and/or parentage. The parent or caretaker relative must have an eligible related dependent child under age 19 living in the home and have income between 0% and 23% of the FPL.
Pregnant Woman:
Pregnant women presenting for services prior to delivery. The income limit for this category is from 0% to 159% of the FPL. No hard copy verification of pregnancy is required. Covers ambulatory prenatal care ONLY.
PE Determination:
A decision of temporary eligibility is called a determination. A Qualified Entity (QE) from a healthcare facility must be trained by the State of Montana in order to make a PE Determination based on self-attested information provided by an individual or household.
Presumptive Eligibility (PE): Expedited eligibility process of determining temporary health care coverage for persons eligible for specific public assistance programs.
Proof of Temporary Coverage Letter:
Approval notices prepared by a QE verifying temporary coverage in a specific public assistance program; used in place of a member ID card.
Qualified Entity (QE):
Representative of a health facility trained and certified to make Presumptive Eligibility determinations.
Self-Attestation:
An applicant’s sworn statement of the accuracy of the information they provide, such as income, household size, and residency, as reported on an application or as a change either verbally, electronically, or in writing.
Web Portal:
On-Line resource site for Qualified Entities and health care providers to check current health care coverage for persons applying for PE (access from the home page of the provider website).
Access to health care is critical for uninsured or underinsured persons when faced with sudden, serious, and often very expensive health care needs. Qualified Entities are vital to the Presumptive Eligibility process. As a Qualified Entity, you are trained and certified to make accurate, complete and timely determinations of PE coverage. Once a person(s) is determined eligible for PE, he/she receives temporary health care coverage for a period not to exceed 60 days. Reimbursement for your facility, and the family’s peace of mind depend upon your due diligence and attention to detail. Once you determine a person presumptively eligible, your facility’s services will be paid covered services on or after the date of your determination, and PE coverage may continue for a period up to the end of the month following the month of determination. If the State later determines a person is/is not eligible for coverage, PE will end at the time of that final determination. If a PE determination is made in error, PE may be denied at the State’s discretion.
* Verify if the person has current coverage and/or
* Verify if the person has received Presumptive Eligibility within the past 12 months:
► Web Portal – www.mtmedicaid.org (see “Eligibility Spans”, example below)
► Fax Back – 1-800-714-0075
► Automated Voice Response – 1-800-714-0060
Web Portal Example 1 (Verify if the person has current coverage):
Web Portal Example 2 (Verify if the person had PE within the past 12 months):
Have the Applicant (or a representative) complete the Presumptive Eligibility Application as follows:
►Page 3 of the application also includes and Addendum for immigrants who need information about whether they are a Qualified Non-Citizen. The Addendum does not need to be submitted with the PE application. See the information from the Addendum later in this chapter.
►"Has Health Insurance" applies only to those who may qualify for HMK PE
ALL PERSONS WHO ARE IMMIGRANTS NEED TO REVIEW THE FOLLOWING INFORMATION TO DETERMINE IF THEY ARE A QUALIFIED NON-CITIZEN; THEN THEY SHOULD MARK THE APPROPRIATE RESPONSE ON THE
PRESUMPTIVE ELIGIBILITY APPLICATION, HOUSEHOLD INFORMATION, COLUMN 8.
Those who are in ANY of the following groups would be considered a Qualified Non-Citizen:
**In order to get Medicaid coverage, under current law most ADULT Lawful Permanent Residents or green card holders have a 5-year waiting period. This means they must wait 5 years after receiving “qualified” immigration status before being eligible for Medicaid. There are also exceptions -- Lawful Permanent Residents who don’t have to wait 5 years -- such as people who used to be refugees or asylees.
Montana has removed the 5-year waiting period to cover lawfully residing children who are otherwise eligible for Medicaid or HMK. A child is “lawfully residing” if lawfully present and otherwise eligible for Medicaid or HMK in the state (including being a state resident).
NOTE: Immigrants who are qualified non-citizens are generally eligible for Medicaid and Children’s Health Insurance Program (HMK) coverage IF they are otherwise eligible for Medicaid and HMK in the state; that is, if they meet Montana’s income eligibility rules.
Before making a PE Determination, a Qualified Entity needs to evaluate which individuals will be “counted” as part of the household. The following examples can be referenced for how to count persons in the household.
Pregnant Women: Include the pregnant woman, the unborn child(ren), the father of the unborn (if married and living together), and any other children (of the unborn’s married parents) under age 19 who live in the home. For example:
Healthy Montana Kids (HMK), Health Montana Kids Plus (HMK Plus), Parent/Caretaker Relative: Include all those on the application that are connected by marriage or parentage who live in the household, along with any unborn children. This includes all Natural, Adoptive, and/or Step Parents and birth, adoptive, or step children under age 19, as well as any unborn children of these persons. DO NOT INCLUDE other adult relatives who file their own tax return. For Example:
Individuals age 19-64: Include all household members that are between the ages of 19 and 64, not pregnant at the time of application, not eligible for or enrolled in Medicare Part A or B, and Parent/Caretaker relatives that are over income for the Parent/Caretaker Relative Medicaid. For Example:
Qualified Entities must complete the “For Office Use only” box for ALL PE Determinations.
Complete the entire box “For Office Use Only.” Copy the “Combined Total Monthly Gross Income” figure from the applicant’s Income information box (page 2 of the PE application). Count how many people are in the household and record the number under “Family Size” in the box shown above. Using the Income Calculation Tool, compare the Total Monthly Gross into to the correct household size to determine the program eligibility for the PE Application. Once the eligible individuals are identified, enter their name, etc. on the “Proof of Temporary Coverage” Form.
The Income Calculation Tool is updated annually to reflect changes to the Federal Poverty Level.
Review the PE application to be certain all of the information is complete. Notify the applicant(s) of any missing information. Remember, QE’s MUST complete the entire “For Office Use Only” box, applicants do not complete any of that information. Complete the Proof of Temporary Coverage form and return it with the completed PE application either by Fax or Scan as directed on the Application and/or Proof of Temporary Coverage.
► Give a copy of the PE application and the Proof of Temporary Coverage letter to the applicant(s).
Notify the applicant(s) of your determination, and let them know they will be receiving a letter confirming Presumptive Eligibility in approximately 10 days.
Within 5 days of the date of determination, Scan the PE Application, and Proof of Temporary Coverage form, create a secure ePass account (Web address: transfer.mt.gov), and email the scanned documents to: HHSPresumptive@mt.gov OR fax the application and Proof of Temporary Coverage form to Central Office at 1-877-418-4533
Be sure to keep a copy of your Fax verification or email record in case DPHHS does not receive it. You might want to keep a copy of the application until the approval is seen in the Web Portal or on the Fax back. You will not be notified of an approval of an application but will you will be notified of a denial.
► Explain to the applicant(s) they will receive a letter confirming PE within approximately 10 days.
► Provide the applicant(s) a copy of the Application for Health Coverage and Help Paying Costs and Appendixes A, B, and/or C.
► Refer them to the appropriate contact in your facility who can assist them with completing the application, gathering any materials necessary for submission with the application, and submission of the application to the State of Montana.
Remember, PE Coverage begins on the Determination Date.
2. Provide the PE Application for completion by the client.
3. Complete the appropriate QE boxes/information on the PE Application AND the Proof of Coverage form.
4. Finalize your determination after evaluating income based on the household size.
5. Sign and date the application after all the information requested on the form has been completed.
6. Give the applicant a copy of the completed PE application, the completed Proof of Temporary Coverage letter, and the Application for Health Coverage and Help Paying Costs.
7. Fax or scan the completed PE Application and Proof of Temporary coverage form to Central office within 5 days of the date of determination.
Please contact us at any time if you have questions, need training or additional supplies, or need to verify any information about presumptive eligibility.
Return to the Presumptive Eligibility Page
In place of an index, this edition has three search options.
End of Index Chapter
End of Presumptive Eligibility Guide
To print this manual, right click your mouse and choose "print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
This publication supersedes all previous Presumptive Eligibility . Published by the Montana Department of Public Health & Human Services, July 2016 and prior. This manual was updated June 2017.
CPT codes, descriptions and other data only are copyright 2014 American Medical Association (or such other date of publication of CPT). All Rights reserved. Applicable FARS/DFARS Apply.
06/152017 The manual was updated to include 2017 requirements and converted to a 508 compliant format.
Please contact us at any time if you have questions, need training or additional supplies, or need to verify any information about presumptive eligibility.
For Training Questions contact:
Justine Welker
Telephone: (406) 708-7075
lvogl@mt.gov
For Eligibility Questions contact:
Alice Lewis
(406) 731-5774
alewis@mt.gov
The Affordable Care Act implemented new regulations giving hospitals and affiliated facilities participating with Medicaid, the option to make Presumptive Eligibility (PE) determinations for special populations. Note: Employees of County Health Departments or similar facilities who made Presumptive Eligibility determination for Pregnant Woman coverage prior to December 31, 2013 may continue to make these determinations after January 1, 2014 based on the new training and methodology, but may not make determinations for other coverage groups.
All providers electing PE must comply with State of Montana requirements for determining PE for the following groups:
► HMK Plus, formerly known as Children’s Medicaid
► HMK, formerly known as Children’s Health Insurance Program (CHIP)
► Parent/Caretaker Relative Medicaid
► Pregnant Woman
► Individuals age 19-64
► Former Foster Care (Individual Care, up to age 26)
► Breast and Cervical Cancer
Benefits for each of these groups vary according to the coverage group. Presumptive eligibility is SHORT TERM coverage. It is only available once every 12 months (or once per pregnancy) and lasts from the date of the determination until a determination of program eligibility is made, OR until the last day of the month following the month of determination, whichever is earlier.
Applicant:
Person applying for coverage for themselves, a spouse, or dependent child
Application:
The Presumptive Eligibility Application
Application for Health Coverage:
The “Application for Health Coverage & Help Paying Costs” used to apply for ongoing health coverage for Medicaid, HMK, or HMK Plus. Appendices A, B, or C may need to be completed if they apply.
Breast and Cervical Cancer:
Women ages 19 through 64 who have been screened and diagnosed with breast or cervical cancer; applicants must present 3 required forms and must not have other insurance which covers cancer treatment.
Determination:
Eligibility decision for Presumptive Eligibility (PE) coverage.
Determination Date:
The date a presumptive eligibility decision is made by a Qualified Entity (QE).
Eligibility Period:
Presumptive Eligibility coverage starts on the date of determination and ends the earlier of: the date a determination of ongoing program eligibility is made, or the end of the month following the month of the PE determination. An applicant may have only one PE period in 12 months, or only one PE Period per pregnancy.
Federal Poverty Level (FPL):
Poverty guidelines for the 48 contiguous stated and the District of Columbia as published under the “Annual Update on HHS Poverty Guidelines” in the Federal Register each year, on or about February 15. The FPL is used in combination with household size to determine presumptive eligibility.
Former Foster Care between ages 18 and 26: Individuals who were in Foster Care and receiving Medicaid when they turned 18. May apply for PE if between ages 18 and 25(until age 26), and should be evaluated for PE as an individual even if living in a household with other family members. No Income limits apply.
Health Montana Kids (HMK):
Formerly known as the Children’s Health Insurance Plan(CHIP), HMK serves eligible children up to age 19 in households with income between 144% and 261% of the FPL.
Health Montana Kids Plus (HMK Plus):
Formerly known as Children’s Medicaid, HMK Plus serves eligible children up to age 19 in households with incomes between 0% and 143% of the FPL.
Income Calculation Tool:
Reference table identifying household size and corresponding maximum income levels for persons or households applying for Presumptive Eligibility.
Individuals ages 19-64:
This expansion group covers individuals ages 19-64 that are not pregnant at the time of application, not eligible for or enrolled in Medicare Part A, not enrolled in Medicare Part B and are between 24% and 133% of the FPL.
Parent/Caretaker Relative Medicaid:
For individuals living together and related by marriage and/or parentage. The parent or caretaker relative must have an eligible related dependent child under age 19 living in the home and have income between 0% and 23% of the FPL.
Pregnant Woman:
Pregnant women presenting for services prior to delivery. The income limit for this category is from 0% to 159% of the FPL. No hard copy verification of pregnancy is required. Covers ambulatory prenatal care ONLY.
PE Determination:
A decision of temporary eligibility is called a determination. A Qualified Entity (QE) from a healthcare facility must be trained by the State of Montana in order to make a PE Determination based on self-attested information provided by an individual or household.
Presumptive Eligibility (PE): Expedited eligibility process of determining temporary health care coverage for persons eligible for specific public assistance programs.
Proof of Temporary Coverage Letter:
Approval notices prepared by a QE verifying temporary coverage in a specific public assistance program; used in place of a member ID card.
Qualified Entity (QE):
Representative of a health facility trained and certified to make Presumptive Eligibility determinations.
Self-Attestation:
An applicant’s sworn statement of the accuracy of the information they provide, such as income, household size, and residency, as reported on an application or as a change either verbally, electronically, or in writing.
Web Portal:
On-Line resource site for Qualified Entities and health care providers to check current health care coverage for persons applying for PE ( access from the home page of the provider website).
Access to health care is critical for uninsured or underinsured persons when faced with sudden, serious, and often very expensive health care needs. Qualified Entities are vital to the Presumptive Eligibility process. As a Qualified Entity, you are trained and certified to make accurate, complete and timely determinations of PE coverage. Once a person(s) is determined eligible for PE, he/she receives temporary health care coverage for a period not to exceed 60 days. Reimbursement for your facility, and the family’s peace of mind depend upon your due diligence and attention to detail. Once you determine a person presumptively eligible, your facility’s services will be paid covered services on or after the date of your determination, and PE coverage may continue for a period up to the end of the month following the month of determination. If the State later determines a person is/is not eligible for coverage, PE will end at the time of that final determination. If a PE determination is made in error, PE may be denied at the State’s discretion.
* Verify if the person has current coverage and/or
* Verify if the person has received Presumptive Eligibility within the past 12 months:
► Web Portal – www.mtmedicaid.org (see “Eligibility Spans”, example below)
► Fax Back – 1-800-714-0075
► Automated Voice Response – 1-800-714-0060
Web Portal Example 1 (Verify if the person has current coverage):
Web Portal Example 2 (Verify if the person had PE within the past 12 months):
Have the Applicant (or a representative) complete the Presumptive Eligibility Application as follows:
►Page 3 of the application also includes and Addendum for immigrants who need information about whether they are a Qualified Non-Citizen. The Addendum does not need to be submitted with the PE application. See the information from the Addendum later in this chapter.
►"Has Health Insurance" applies only to those who may qualify for HMK PE
ALL PERSONS WHO ARE IMMIGRANTS NEED TO REVIEW THE FOLLOWING INFORMATION TO DETERMINE IF THEY ARE A QUALIFIED NON-CITIZEN; THEN THEY SHOULD MARK THE APPROPRIATE RESPONSE ON THE
PRESUMPTIVE ELIGIBILITY APPLICATION, HOUSEHOLD INFORMATION, COLUMN 8.
Those who are in ANY of the following groups would be considered a Qualified Non-Citizen:
**In order to get Medicaid coverage, under current law most ADULT Lawful Permanent Residents or green card holders have a 5-year waiting period. This means they must wait 5 years after receiving “qualified” immigration status before being eligible for Medicaid. There are also exceptions -- Lawful Permanent Residents who don’t have to wait 5 years -- such as people who used to be refugees or asylees.
Montana has removed the 5-year waiting period to cover lawfully residing children who are otherwise eligible for Medicaid or HMK. A child is “lawfully residing” if lawfully present and otherwise eligible for Medicaid or HMK in the state (including being a state resident).
NOTE: Immigrants who are qualified non-citizens are generally eligible for Medicaid and Children’s Health Insurance Program (HMK) coverage IF they are otherwise eligible for Medicaid and HMK in the state; that is, if they meet Montana’s income eligibility rules .
Before making a PE Determination, a Qualified Entity needs to evaluate which individuals will be “counted” as part of the household. The following examples can be referenced for how to count persons in the household.
Pregnant Women: Include the pregnant woman, the unborn child(ren), the father of the unborn (if married and living together), and any other children (of the unborn’s married parents) under age 19 who live in the home. For example:
Healthy Montana Kids (HMK), Health Montana Kids Plus (HMK Plus), Parent/Caretaker Relative: Include all those on the application that are connected by marriage or parentage who live in the household, along with any unborn children. This includes all Natural, Adoptive, and/or Step Parents and birth, adoptive, or step children under age 19, as well as any unborn children of these persons. DO NOT INCLUDE other adult relatives who file their own tax return. For Example:
Individuals age 19-64 : Include all household members that are between the ages of 19 and 64, not pregnant at the time of application, not eligible for or enrolled in Medicare Part A or B, and Parent/Caretaker relatives that are over income for the Parent/Caretaker Relative Medicaid. For Example:
Qualified Entities must complete the “For Office Use only” box for ALL PE Determinations.
Complete the entire box “For Office Use Only.” Copy the “Combined Total Monthly Gross Income” figure from the applicant’s Income information box (page 2 of the PE application). Count how many people are in the household and record the number under “Family Size” in the box shown above. Using the Income Calculation Tool, compare the Total Monthly Gross into to the correct household size to determine the program eligibility for the PE Application. Once the eligible individuals are identified, enter their name, etc. on the “Proof of Temporary Coverage” Form.
The Income Calculation Tool is updated annually to reflect changes to the Federal Poverty Level.
Review the PE application to be certain all of the information is complete. Notify the applicant(s) of any missing information. Remember, QE’s MUST complete the entire “For Office Use Only” box, applicants do not complete any of that information. Complete the Proof of Temporary Coverage form and return it with the completed PE application either by Fax or Scan as directed on the Application and/or Proof of Temporary Coverage.
► Give a copy of the PE application and the Proof of Temporary Coverage letter to the applicant(s).
Notify the applicant(s) of your determination, and let them know they will be receiving a letter confirming Presumptive Eligibility in approximately 10 days.
Within 5 days of the date of determination, Scan the PE Application, and Proof of Temporary Coverage form, create a secure ePass account (Web address: transfer.mt.gov), and email the scanned documents to: HHSPresumptive@mt.gov OR fax the application and Proof of Temporary Coverage form to Central Office at 1-877-418-4533
Be sure to keep a copy of your Fax verification or email record in case DPHHS does not receive it. You might want to keep a copy of the application until the approval is seen in the Web Portal or on the Fax back. You will not be notified of an approval of an application but will you will be notified of a denial.
► Explain to the applicant(s) they will receive a letter confirming PE within approximately 10 days.
► Provide the applicant(s) a copy of the Application for Health Coverage and Help Paying Costs and Appendixes A, B, and/or C.
► Refer them to the appropriate contact in your facility who can assist them with completing the application, gathering any materials necessary for submission with the application, and submission of the application to the State of Montana.
Remember, PE Coverage begins on the Determination Date.
2. Provide the PE Application for completion by the client.
3. Complete the appropriate QE boxes/information on the PE Application AND the Proof of Coverage form.
4. Finalize your determination after evaluating income based on the household size.
5. Sign and date the application after all the information requested on the form has been completed.
6. Give the applicant a copy of the completed PE application, the completed Proof of Temporary Coverage letter, and the Application for Health Coverage and Help Paying Costs.
7. Fax or scan the completed PE Application and Proof of Temporary coverage form to Central office within 5 days of the date of determination.
Please contact us at any time if you have questions, need training or additional supplies, or need to verify any information about presumptive eligibility.
For Training Questions contact:
Alice Lewis
(406) 731-5774
alewis@mt.gov
For Eligibility Questions contact:
Justine Welker
(406) 883-7848
jwelker@mt.gov
Return to the Presumptive Eligibility Page
In place of an index, this edition has three search options.
End of Presumptive Eligibility Guide